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0 <br /> Consent Form Requirements <br /> I lealth and Sarety Code <br /> Client is at least 18 years of age - 119302 (a) <br /> El -N.u-ents/Guardlan signature of minor receiving body piercing -- 119302 (b) <br /> ;D <br /> Signature oI-client agreeing they have, read and completed the consent form- 1193)03 (a) <br /> Description of procedure--- 1193103 (a) I <br /> -Description of what the client s1,0111cl expect ri.)1lowhia the procedure - 199303 (a) 2 <br /> Statement regardin-D permanent nature of procedure- 119303 (a) 3 <br /> LL--I Post procedure instructions- 119303 (a)4 <br /> a).-ififormation of proper care for procedure site <br /> ­gpi-estrictions on physical activities <br /> c sions and symptoms of infection <br /> --5'�- Ijjaications when to seek medical care <br /> Medical Questionnaire <br /> H&SC 119303 (b) <br /> Client status regarding pregnancy- 119303 (b) I <br /> ,History of herpes infection at the procedure site- 119303 (b)2 <br /> -Er" History of diabetes- 119303 (b)2 <br /> History of allergic reactions to latex-119303)03 (b)2 <br /> 1.3 <br /> History of allergic reactions to antibiotics- 119303 (b)2 <br /> History of hemophilia or other bleeding disorders- 119303 (b)2 <br /> -0---f-listory of cardiac valve disease 11930') (b)2 <br /> Current medications- 119303 (b)3 <br /> Requirements for antibiotics prior to surgery or dental procedures- 119303 (b) 3) <br /> --fT— Other risk factors for blood borne pathogens- 119303 (b) 4 <br />